Skip to main content

How IPPS Proposed Rules Would Affect Quality Measures

 |  By cclark@healthleadersmedia.com  
   May 03, 2012

The latest proposed rules for how federal payers would reimburse hospitals in years to come call for important changes in the way quality is measured. But you wouldn't know it unless you dug through the 1,313-page proposal for Inpatient Prospective Payment System rules.

I don't expect you to scour the whole thing.

But I browsed through parts of it and found that not only does the Centers for Medicare & Medicaid Services intend to increase the types of hospital performance that influence hospital payments, but these new performance measures also would be publicly reported on Hospital Compare someday soon.

Some other elements in the mix should prompt quality leaders to refocus their resources. I'll list five that merit particular attention.

1. Amendments to the HCAHPS survey related to preventing readmissions.
On Jan. 1, 2013, three questions measuring how well hospitals informed patients on how to manage their conditions after their discharge, a high CMS priority to prevent costly readmissions, would be added to the Hospital Consumer Assessment of Healthcare Providers and Systems survey list for payments as of Oct. 1, 2014 or FY 2015.

To all these discharge planning questions, patients can answer that they strongly disagree, disagree, agree, or strongly agree.

  • "During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left."
  • "When I left the hospital, I had a good understanding of the things I was responsible for in managing my health." 
  • "When I left the hospital, I clearly understood the purpose for taking each of my medications."  For this third question, a respondent has another answer option: "I was not given any medication when I left the hospital."

Two new questions would ask how the patient came to the hospital, and about the patient's mental or emotional health status. The answers would not be publicly reported, but could help CMS risk adjust the responses for validity.

2. Pay for reporting of unplanned, any-cause hospital-wide readmissions.
Because readmissions for any cause within 30 days cost Medicare an estimated $17 billion annually and affect nearly one in five beneficiaries, and because currently measured readmissions reflect only those for patients with pneumonia, heart failure and heart attack, CMS seeks to expand the categories for reporting for which it pays hospitals an incentive of 2%.

Under a separate section of the Affordable Care Act, hospitals with higher rates of readmissions of patients with any of these three conditions are already penalized between 1% and 3% of their Medicare DRG payments, but many hospitals don't have enough of those patients for a fair comparison.

This new readmission metric, which would affect payments as of Oct. 1, 2014, would provide "a broader sense of the quality of care in hospitals," the agency said. CMS says that successful programs have reduced these all-cause readmission rates between 20% and 40%.

Readmissions would be counted as a single score for medicine, surgery/gynecology, cardiorespiratory, cardiovascular and neurology procedures.

Addressing one controversial aspect, CMS would exclude 36 procedure categories for which a readmission may have been reasonably expected or planned.

3. The number of elective hip and/or knee arthroscopic surgeries that resulted in complications or readmissions.
Complication rates for these ubiquitous procedures range from 2.2% to 8.9%, which indicates to CMS that important quality differences among hospitals providing these surgeries are pervasive.

CMS proposes to measure outcomes such as death, pulmonary embolism, surgical site bleeding, or wound infection within 30 days of admission; heart attack, pneumonia or sepsis occurring within seven days of admission; and mechanical complications and periprosthetic joint infections within 90 days of admission.

CMS wants to track these complications because the number of these procedures—202,500 total hip and 402,100 total knee in 2003—continues to grow with a projected annual charge to Medicare estimated at $58 billion by 2015.  "The post-operation complications of these procedures are high considering these are selective procedures and usually the complications are devastating to patients."

CMS also plans to add the number of times patients who underwent a hip or knee surgery required a readmission within 30 days to the pay for reporting program effective for discharges as of Oct. 1, 2014.

Readmission rates for these procedures range from 3.06% to 50.94%, a variation that "suggests there are important differences in the quality of care received across hospitals, and there is room for improvement," the agency said.

4. Elective pre-term deliveries between 37 and 39 weeks of gestation that weren't medically necessary.
Saying that early elective deliveries are "a growing public health problem" that increases the likelihood of complications and long-term health problems for mother and baby, CMS officials say they want to start collecting hospital data starting Jan. 1. Results would be reflected in payment as of Oct. 1, 2014.

Pre-term births, many of which that take place simply for the convenience of the physician, hospital or parent, have increased by 36% over the last two decades.  CMS is concerned because Medicare last year paid for 14,000 births among beneficiaries" who have the potential to be impacted by pre-term births."

5. Hospital Acquired Conditions (HAI)
CMS proposes to add two conditions to the list of Hospital Acquired Conditions for discharges occurring on or after Oct. 1, 2012.

The first includes surgical site infections, usually Staphylococcus aureus, following a cardiac implantable electronic device (CIED) procedure.

The proposed rule states that at least 500,000 devices are implanted each year and 70% of the recipients are Medicare eligible. However, infections resulting from these implants are increasing faster than the rate of increase in the procedures, the agency says.

These infections often necessitate surgical removal of the device, anesthesia, intravenous antibiotics, and time in the ICU. Between 5% and 8% of patients die in the hospital and 17.5% to 35.1% within a year.

And they're expensive. CMS said studies show that the cost of treating these complications is steep, averaging "$28,676 to $53,349" and as high as high as $72,485 per case.

But these infections are reasonably preventable through precautions such as prophylactic antibiotics, which one study showed can reduce CIED-related infections in 81% of patients who received them.

The second HAI condition is the incidence of pneumothorax with venous catheterization. This happens when a medical intervention, such as a needle placement for central line catheter guidance, inadvertently results in collapse of the lung.

However, use of portable ultrasound devices can guide placement to avoid these complications.

As usual, CMS seeks comments and will issue a final rule by August. The proposed rule may be downloaded from the Federal Register.

Tagged Under:


Get the latest on healthcare leadership in your inbox.